Comparative analysis of Cochrane and non-Cochrane reviews over three decades

Background Systematic reviews are viewed as the best study design to guide clinical decision-making as they are the least biased publications assuming they are well-conducted and include well-designed studies. Cochrane was initiated in 1993 with an aim of conducting high-quality systematic reviews. We aimed to examine the publication rates of non-Cochrane systematic reviews (henceforth referred to simply as “systematic reviews”) and Cochrane reviews produced throughout Cochrane’s existence and characterize changes throughout the period. Methods This observational study collected data on systematic reviews published between 1993 and 2022 in PubMed. Identified Cochrane reviews were linked to data from the Cochrane Database of Systematic Reviews via their Digital Object Identifier. Systematic reviews and Cochrane reviews were analyzed separately. Two authors screened a random sample of records to validate the overall sample, providing a precision of 98%. Results We identified 231,602 (94%) systematic reviews and 15,038 (6%) Cochrane reviews. Publication of systematic reviews has continuously increased with a median yearly increase rate of 26%, while publication of Cochrane reviews has decreased since 2015. From 1993 to 2002, Cochrane reviews constituted 35% of all systematic reviews in PubMed compared with 3.5% in 2013–2022. Systematic reviews consistently had fewer authors than Cochrane reviews, but the number of authors increased over time for both. Chinese first authors conducted 15% and 4% of systematic reviews published from 2013–2022 and 2003–2012, respectively. Most Cochrane reviews had first authors from the UK (36%). The native English-speaking countries the USA, the UK, Canada, and Australia produced a large share of systematic reviews (42%) and Cochrane reviews (62%). The largest publishers of systematic reviews in the last 10 years were gold open access journals. Conclusions Publication of systematic reviews is increasing rapidly, while fewer Cochrane reviews have been published through the last decade. Native English-speaking countries produced a large proportion of both types of systematic reviews. Gold open access journals and Chinese first authors dominated the publication of systematic reviews for the past 10 years. More research is warranted examining why fewer Cochrane reviews are being published. Additionally, examining these systematic reviews for research waste metrics may provide a clearer picture of their utility. Supplementary Information The online version contains supplementary material available at 10.1186/s13643-024-02531-2.


Introduction
The amount of scientific literature is growing exponentially [1].With the introduction of evidence-based medicine in the late part of the twentieth century, synthesizing evidence became an area of focus [2].The principles of evidence-based medicine dictate that the best clinical guidance should be based on the least biased and most up-to-date evidence available.This comes in the form of systematic reviews and meta-analyses, which are generally viewed as the study design that is least likely to be biased, assuming they are well-conducted and based on methodologically rigorous studies [3], and thereby providing the best evidence for informing decision-makers [4,5].In 1993, the Cochrane Collaboration (now "Cochrane") was founded on the same ideals as evidencebased medicine was built upon, with an aim of providing systematic reviews and meta-analyses of high quality [6].While there are examples of synthesizing evidence systematically several hundred years ago [7,8], the development of the methodology and frequency of publication of systematic reviews has accelerated during the last 30 years where Cochrane has existed.Cochrane has played a considerable role in developing a thorough systematic review methodology [9,10] and creating software to ease the production of systematic reviews, e.g., RevMan Web (Review Manager Web, version 4.12.0,The Cochrane Collaboration, 2022).Other non-Cochrane initiatives to streamline and improve systematic review methodology have also been developed, e.g., the Metaanalyses of Observational Studies in Epidemiology (MOOSE) guideline [11], the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline [12], and the Joanna Briggs Institute guidelines [13].However, with the development and distribution of systematic review methodology, it is unclear how the distribution of systematic review production through the years has changed.
We aimed to characterize changes in publication of non-Cochrane systematic reviews (henceforth referred to simply as "systematic reviews") and Cochrane reviews throughout Cochrane's existence.Our primary objective was to determine the yearly publication rates of systematic reviews and Cochrane reviews through a 30-year period from 1993 to 2022.Our secondary outcome was to further characterize changes for both types of reviews.

Reporting, eligibility criteria, and validation
This observational study was reported according to the RECORD guideline where applicable [14] as it was based on routinely collected metadata (Appendix).Records were eligible for inclusion if they were any type of systematic reviews published between 1993 and 2022 and indexed in PubMed or the Cochrane Database of Systematic Reviews (CDSR).All types of published systematic reviews were included, i.e., also updated Cochrane reviews, withdrawn Cochrane reviews [15], and retracted systematic reviews.We chose this period as it was the time from the creation of the CDSR until the last full calendar year before our date of search.We excluded records with missing data such as title, journal, or year; records with publication date registered before 1993 or in 2023; protocols of Cochrane reviews, which was assessed via metadata from the CDSR regarding the stage of the report; duplicate records; and protocols of systematic reviews by searching the title of records for the terms "review protocol, " "protocol for a systematic, " "protocol of a systematic, " "protocol for the systematic, " "protocol of the systematic, " "protocol for systematic, " and "protocol of systematic." The terms for systematic review protocols were determined by pilot searches.We performed additional pilot investigations of the extracted data to determine the best options for data cleaning.As our pilot investigations indicated errors in the indexation of publication date for early Cochrane reviews, we matched Cochrane reviews from PubMed to the CDSR based on their Digital Object Identifier (DOI) and collected data on publication date from the CDSR.The country of the first author was extracted in an automated fashion from the registered first author affiliation from the PubMed metadata.All countries that appeared over 100 times after data cleaning were validated manually and integrated into the analysis.Furthermore, for the Cochrane reviews, we screened all records with more than one country mentioned in the affiliations and looked up unresolved countries to integrate these into the final analysis.For further validation, we screened a random sample of 1182 without replacement of the extracted records (0.5%) and determined a precision [16].Two authors independently screened the 1182 random records from the Pub-Med sample for relevance.Relevant records were defined as either identifying as a systematic review or conducting a literature review via a systematic search.Records were initially screened on title, subsequently abstract, and finally full text if needed.Conflicts were resolved through discussion between the two authors.In total, 21 records from the sample were irrelevant correlating to a precision of 98%.We found no sign of systematic errors among the 21 ineligible records, thus, there was no further exclusion of records.

Data sources, linkage, variables, and study size
Data were obtained through an Application Programming Interface (API) and Entrez Direct Server, for PubMed [17], and linked with the CDSR [18] via the Cochrane Reviews' unique DOI.PubMed is the most used biomedical scholarly database and provides good coverage of biomedical literature [19].At the time of data extraction, the systematic review filter in PubMed was accurate and up to date (S Schmidt, Senior Technical Information Specialist, National Library of Medicine, personal communication, 04 April 2023).The search of PubMed was done via Entrez Direct Server on 26 April 2023.We extracted data on systematic review characteristics (title, authors, publication date, journal, International Standard Serial Number (ISSN), affiliations, funding, conflicts of interest statement, and DOI) through indexed metadata in PubMed via the API and from the CDSR.During reporting, countries were abbreviated following the United Nations Conference on the Standardization of Geographical Names abbreviations [20].The study size was determined by the records obtained that met our inclusion criteria and none of the exclusion criteria.We did not attempt to limit the sample.

Statistical analyses
Data were descriptively analyzed for the full 30-year period and in three separate subgroups each covering a 10-year period: 1993-2002, 2003-2012, and 2013-2022.The number of authors was handled as continuous data and was reported with mean and standard deviation.Yearly percentual increase was calculated and displayed tabulated.Systematic reviews' and Cochrane reviews' growth rates were presented graphically by scaling the increases of the yearly number of reviews to a shared range between 0 and 1 by unity-based normalization.Other data were handled as categorical variables and reported as number and percent.Statistical analyses were done in Python v3.10, using Pyspark v3. 4

Results
We extracted 264,127 records from PubMed.Two records were excluded as they had no registered date.Subsequently, 15,330 records were excluded for being published either before 1993 (n = 33) or in 2023 (n = 15,297), and 1344 were excluded for being protocols of systematic reviews.After a manual assessment of DOI duplicates, further 50 records were excluded.After DOI-matching to the CDSR, a total of 246,640 records were analyzed, of which 231,602 (93.9%) were systematic reviews and 15,038 (6.1%) were Cochrane reviews (Table 1).
Characteristics expressed as number (%) or mean ± standard deviation of included non-Cochrane systematic reviews and Cochrane reviews for periods of 10 years and the total 30-year period.Regarding countries, the top five most common countries of first author affiliations for the given periods were listed with the total number of systematic reviews published.Countries are abbreviated following the United Nations Conference on the Standardization of Geographical Names abbreviations [20].Data were collected from PubMed and data on Cochrane reviews were linked via the records Digital Object Identifier.For each outcome, n represents how many records had data available for the outcome.
The number of published systematic reviews increased continuously throughout the 30-year period (Fig. 1) with a median yearly increase rate of 26% (Table 2).Meanwhile, Cochrane reviews reached their peak in productivity in 2013 and growth rates fluctuated over the whole 30-year period with a median yearly increase of 3%.Since 2015, Cochrane reviews have been published less frequently (Figs. 1, 2 and Table 2).For the period 1993-2002, 1377 Cochrane reviews were published, constituting 35% of all systematic reviews indexed in PubMed (Fig. 1).For the period 2013-2022, 7240 Cochrane reviews were published corresponding to 3.5% of all systematic reviews in  authors published 4 (0.2%) and 1079 (4%) systematic reviews, respectively.Generally, the native English-speaking countries the USA, the UK, Canada, and Australia combined produced a large proportion of the published systematic reviews for both systematic reviews (86,835, 42%) and Cochrane reviews (8999, 62%) (Fig. 3).The UK had produced most Cochrane reviews throughout the 30-year period (5213, 36%) and for all 10-year intervals, but the share of Cochrane reviews produced by UK first authors was decreasing (Fig. 3).In the first 10 years of the period, high-impact journals such as the BMJ, JAMA, and Lancet were among the journals publishing most

Discussion
In this observational study, we found that the number of published systematic reviews has increased considerably, whereas Cochrane's relative share of systematic reviews has decreased throughout its existence.While systematic reviews increased, the publication of Cochrane reviews has decreased steadily since 2015.During the last decade, Chinese first authors produced a large portion of systematic reviews.Gold open access journals were the largest publishers of systematic reviews from 2013 to 2022, whereas high-impact journals were the largest publishers of systematic reviews from 1993 to 2002.The number of authors seemed to increase over time.
We found that publication of systematic reviews is growing rapidly.Compared with other general publications in life sciences, where authors found a growth rate of 5.1% [1], systematic reviews are growing faster.Our findings show that while the motivation for publishing systematic reviews was high, Cochrane reviews were being published less frequently.Cochrane reviews are known to take a long time to complete [21][22][23] compared with systematic reviews [24][25][26].This may be partly due to the process of a Cochrane review having more mandatory steps involved, e.g., minimum requirements for databases searched, searching trial registries, and requirements regarding which analyses to conduct.This may also explain why they are known overall to be of higher quality [27][28][29][30][31][32] and are valuable for developing healthcare policies [33].The thought of high demands for resources and long publication times may intimidate potential authors.However, despite this, Cochrane's author satisfaction was generally high [34].Recently, Cochrane has begun rethinking their publication model [35] with several key projects aimed at improving the author experience and optimizing the publication process [36].
We found that balances had shifted relating to production and publication of systematic reviews over the past 10 years.Regarding production, especially systematic reviews written by Chinese first authors have expanded, increasing their publication of systematic reviews by a factor of 25 from 2003-2012 to 2013-2022.The same productivity increase among Chinese authors was not seen in Cochrane reviews.Despite the rapid increase in productivity, one Chinese study found similar methodological and reporting quality between Chinese systematic reviews and those from the USA [37].Regarding publication, gold open access journals had grown to be the largest publishers of systematic reviews from 2013 to 2022.Open access has been gaining popularity and may be a step in the right direction for science [38].However, gold open access journals operate with article processing charges that authors must pay to get their papers published.These charges can be steep and have been increasing rapidly over time [39].There is a wish within the scientific community to transition to a diamond openaccess model, where articles are published open access but without authors or readers having to pay exorbitant fees [40].While this is undoubtedly desirable, there are still costs associated with academic publishing and determining how the diamond open-access model should be financed is not an easy matter.With the increasing amount of research production, there has been discussion of "research waste" [41], i.e., unnecessary and noncontributing research.It was argued already in 1994, at the beginning of our inclusion period, that the scientific community should aim towards producing fewer reviews and instead focus on increasing the quality of publications [42].Since then, we have had 30 years of exponential increase in evidence synthesis.Relating to this concept, several suggestions towards reducing redundancy of reviews have been put forward [43].Addressing research waste seems to be a topic gaining focus [43,44].We also found an increasing number of authors through time.This aligns with the findings of other studies [45,46].This may relate to an increasing amount of data in modern research thereby increasing complexity [47].One study, however, found that adjusting for factors relating to increased complexity did not explain the increase in authorship when it came to trials and non-randomized studies [48].Furthermore, systematic reviews differ from clinical trials in that data are available remotely through searches, and therefore, the resource demands may be lower.Interestingly, Cochrane reviews had fewer authors than systematic reviews.This may seem counterintuitive, as Cochrane reviews generally have higher demands and should therefore demand more resources.It is not clear what is causing the increasing number of authors in medicine.
Our study had several strengths.Firstly, we analyzed a very large dataset with the goal of having generalizable conclusions.We only searched PubMed, which is a biomedical database, where records are manually screened for indexation as systematic reviews.We thereby avoided a great deal of false positives that traditional searching would produce.This was demonstrated by validating the search and finding a practical precision of 98%.Generally, searches in large bibliographic databases have low precision [49].One of the authors, a professional data analyst, conducted data cleaning to adjust for wrongly registered data.Furthermore, we collected data on publication dates from the CDSR, which is the primary source of Cochrane reviews.Therefore, we are confident that Cochrane reviews were correctly and sufficiently identified.However, our study also had some limitations.With large datasets, it is likely there were some miscategorized records.Based on our precision estimate and after data cleaning, we estimate this to be about 2% overall, but some areas may have had more than others.Despite the National Library of Medicine's personal screening of records, we still found some protocols indexed as systematic reviews, indicating that the systematic review filter, while good, is not 100% perfect.Still, it is a more reliable method of retrieving systematic reviews than through searches and the most feasible method owing to the size of our sample.While searching PubMed ensured high external validity, there are undoubtedly more systematic reviews produced in the period indexed in other databases.However, correcting for this bias in our results would only exaggerate the conclusion that systematic reviews are increasing rapidly and constitute an increasingly larger portion of all systematic reviews compared with Cochrane reviews.On the other hand, a small portion of the increase in systematic reviews may be attributed to the post-indexation of older records and journals in PubMed.We do not believe this potential bias would impact the overall conclusions.Generally, we are confident that the assumed miscategorized data would not change the overall conclusions.This study cannot address the quality of the included systematic reviews or if there is an overlap of the research question of these systematic reviews, thus, whether unnecessary systematic reviews are being published.
It is unclear why Cochrane reviews were being published less frequently in the past 10 years.As Cochrane reviews are expected to be updated and despite them not always being updated frequently [50], we expected the number to increase given the combination of new Cochrane reviews being published and older ones being updated.It may be favorable to have more Cochrane reviews published, as they are generally of high quality owing to their thorough peer review process and rigorous methodology [27][28][29][30][31][32].Some of the decrease in publication of Cochrane reviews may be due to them generally taking a long time to complete [21][22][23] and including many procedural and methodological demands [9,10].Future studies exploring why Cochrane reviews were being published less frequently are warranted.The continually increasing publication rates of systematic reviews may risk an information overload, where stakeholders cannot reasonably stay orientated and updated with new literature.It is, however, unclear to which degree the increase in publication of systematic reviews results from overlapping or redundant reviews being published, or if the new studies, in general, are of value to the research community.Further research into field overlap and the methodological quality of newer systematic reviews may clarify this.
In conclusion, the publication of systematic reviews has increased rapidly in the past 30 years, while fewer Cochrane reviews have been published since 2015.Especially Chinese first authors conducted many systematic reviews through the last 10 years.For the same period, gold open access journals were the largest publishers of systematic reviews.It may be favorable to have more Cochrane reviews published, as these are generally of higher quality than systematic reviews.Furthermore, further research regarding metrics related to research waste may clarify questions regarding the utility and value of systematic reviews throughout time.

Appendix
PubMed for the period, and in 2022 alone, 344 Cochrane reviews were published, corresponding to a share of 0.8%.Systematic reviews had a mean of 3.6 authors per review in 1993-2002, which increased to 5.9 in 2013-2022.Meanwhile, Cochrane reviews had 3.2 authors in 1993-2002, which increased to 5.3 in 2013-2022.Cochrane reviews continuously had fewer authors than systematic reviews for all 10-year periods.From 2013-2022, Chinese first authors published most systematic reviews (27,230, 15%).Meanwhile, for Cochrane reviews in the same period, Chinese first authors published 5% of these.From 1993-2002 and 2003-2012, Chinese first

Fig. 1
Fig. 1 Absolute change in non-Cochrane systematic reviews and Cochrane reviews.Total number (y-axis) of non-Cochrane systematic reviews (light blue) indexed in PubMed and Cochrane reviews (purple) indexed in the Cochrane Database of Systematic Reviews published per year (x-axis) from 1993 to 2022 as absolute number (A) and expressed logarithmically (B)

Fig. 2
Fig. 2 Normalized yearly change of non-Cochrane systematic reviews and Cochrane reviews.Unity-based normalization in a range of [0, 1] of absolute yearly changes in non-Cochrane systematic reviews and Cochrane reviews

Fig. 3
Fig. 3 Country of first authors for non-Cochrane systematic reviews and Cochrane reviews.The plot of the number of publication (y-axis) of Cochrane reviews (A) and non-Cochrane systematic reviews (B) by the top 10 first-author affiliated countries from 1993 to 2022 (x-axis).Analysis was based on 14,614 records (97%) (A) and analysis was based on 207,253 records (89%) (B)

Table 1
Characteristics of non-Cochrane systematic reviews and Cochrane reviews

Table 2
Yearly percentual increase or decrease (indicated by negative numbers) in publication of non-Cochrane systematic reviews and Cochrane reviews throughout the 30-year period

Table 3
Journals publishing non-Cochrane systematic reviews.National Library of Medicine (NLM) abbreviations of journals with most published non-Cochrane systematic reviews based on International Standard Serial Number (ISSN) expressed as follows: total number (%).For ISSN see Supplementary File 1